What are the indications and advantages of using midline catheters, Peripherally Inserted Central Catheters (PICC) lines, and Central Venous Catheters (CVC) for intravenous therapy?

Venous Access Device Selection: PICC vs CVC vs Midline

For peripherally compatible infusates lasting 6-14 days, prefer midline catheters over PICCs due to lower complication rates; reserve PICCs for durations ≥15 days or when central access is required for vesicants/irritants. 1

Duration-Based Algorithm for Peripherally Compatible Infusates

≤5 Days

• Use peripheral IV catheters or ultrasound-guided peripheral IVs 1
• PICCs are inappropriate for this duration 1
• CVCs appropriate only if skilled operators available AND patient requires frequent phlebotomy or has difficult venous access 1

6-14 Days

• Prefer midline catheters as first-line 1
• Midlines demonstrate lower complication rates than PICCs for this interval 1
• PICCs are appropriate but second-line for this duration 1
• CVCs appropriate for ≤14 days if skilled operators available 1

15-30 Days

• PICCs are preferred over midlines due to higher midline failure rates beyond 14 days 1
• Midlines can be used up to 4 weeks but have increased failure risk after 14 days 1

≥31 Days

• Tunneled catheters or implanted ports become appropriate 1
• Reserve these invasive devices for when PICCs are not feasible (no suitable vein, contraindicated due to recent thrombosis) or episodic infusions over months are needed 1

Infusate Type Determines Device Selection

Vesicants/Irritants (Parenteral Nutrition, Chemotherapy)

• PICCs appropriate at ANY duration because central access is mandatory 1
• Midline catheters are INAPPROPRIATE for vesicants/irritants at all durations—they do not provide central venous access 1
• Nontunneled CVCs appropriate for ≤14 days if skilled operators available 1
• Tunneled catheters appropriate for ≥15 days 1
• Implanted ports appropriate for ≥31 days 1

Peripherally Compatible Solutions

• Follow duration-based algorithm above
• Solutions with pH 5-9 or osmolarity <500 mOsm are appropriate for midlines 2

Critical Care Patients: Different Thresholds

Hemodynamically Stable

• Peripheral IVs or midlines for ≤5 days 1
• Midlines for 6-14 days 1
• PICCs inappropriate unless duration ≥15 days 1
• CVCs appropriate for 6-14 days 1

Hemodynamically Unstable or Requiring Invasive Monitoring

• CVCs strongly preferred over PICCs 1, 3
• CVCs appropriate for ≤14 days 1
• PICCs appropriate for ≥15 days 1
• Urgent PICC placement is inappropriate in unstable patients 1, 3

Coagulopathy Present

• Prefer PICCs over CVCs to avoid insertion complications, especially if use >15 days expected 1

Special Populations

Chronic Kidney Disease (Stage 3-5)

• Avoid PICCs entirely in patients at risk for future hemodialysis access 1, 3
• Use small-bore catheters via internal jugular vein if central access needed 1
• Avoid subclavian vein to preserve future dialysis access 1

Cancer Patients (Hospitalized)

• Raise threshold for PICC use: appropriate only for ≥15 days 1
• Midlines appropriate for ≤14 days 1
• For long-term chemotherapy >6 months: implanted ports preferred due to lowest infection rates 1, 3

Difficult Venous Access or Frequent Phlebotomy (≥3/day)

• Ultrasound-guided peripheral IVs or midlines preferred for ≤14 days 1
• PICCs appropriate for ≥6 days 1
• CVCs appropriate for ≤14 days 1

Key Advantages by Device Type

Midline Catheters

• Lower complication rates than PICCs for 6-14 day duration 1
• No chest X-ray required for placement confirmation 2
• Can be placed at bedside 4
• Dwell time up to 14 days safely, possibly up to 28 days 2, 5
• Reduced need for additional vascular access devices 6
• Lower healthcare costs compared to PICCs 6

PICCs

• Mandatory for vesicants/irritants at any duration 1
• Appropriate for durations ≥15 days with peripherally compatible infusates 1
• Can remain in place for months 5
• Preferred over tunneled catheters in patients with coagulopathy or thrombocytopenia 1

CVCs (Nontunneled)

• Immediate bedside access in emergencies 3
• Preferred in hemodynamically unstable patients 1, 3
• Appropriate for ≤14 days 1
• Subclavian insertion has 10× lower thrombosis risk than femoral 3
• Subclavian insertion has lower infection rates than jugular 3

Common Pitfalls to Avoid

• Do not place PICCs for <6 days with peripherally compatible infusates—this is inappropriate and increases unnecessary complications 1
• Do not use midlines for vesicants/irritants—they lack central access and risk extravasation 1
• Do not place PICCs in CKD patients at risk for dialysis—this compromises future access 1, 3
• Do not use femoral CVCs when subclavian is feasible—femoral has 10× higher thrombosis risk 3
• Do not urgently place PICCs in hemodynamically unstable patients—CVCs are preferred 1, 3